How Is Telehealth Currently Being Utilized to Help in Hypertension Management within Primary Healthcare Settings? A Scoping Review

Telehealth has improved patient access to healthcare services and has been shown to have a positive impact in various healthcare settings. In any case, little is understood regarding the utilization of telehealth in hypertension management in primary healthcare (PHC) settings. This study aimed to identify and classify information about the types of interventions and types of telehealth technology in hypertension management in primary healthcare. A scoping review based on PRISMA-ScR was used in this study. We searched for articles in four databases: Pubmed, Scopus, Science Direct, and Embase in English. The selected articles were published in 2013–2023. The data were extracted, categorized, and analyzed using thematic analysis. There were 1142 articles identified and 42 articles included in this study. Regarding the proportions of studies showing varying trends in the last ten years, most studies came from the United States (US) (23.8%), were conducted in urban locations (33.3%), and had a quantitative study approach (69%). Telehealth interventions in hypertension management are dominated by telemonitoring followed by teleconsultation. Asynchronous telehealth is becoming the most widely used technology in managing hypertension in primary care settings. Telehealth in primary care hypertension management involves the use of telecommunications technology to monitor and manage blood pressure and provide medical advice and counselling remotely.


Background
Most health systems share common goals of improving patient health, being responsive to patient needs, and ensuring financial sustainability [1].Health systems differ between countries in terms of their structure, financing, and outcomes.Factors such as socioeconomic status, political framework, and cultural diversity contribute to these differences.For example, the US does not have a universal healthcare system, and most Americans receive health insurance through their employers [2].In contrast, countries like Canada and the UK have universal healthcare systems that are publicly funded [3].Countries like Japan, Republic of Korea, Singapore, the United Arab Emirates, Australia, and New Zealand provide healthcare to almost all residents, with residents paying some healthcare costs out of pocket [4].Economic globalization has also played a role, leading to the commercialization of healthcare services and weakening national health systems, particularly in low-income countries [5].The healthcare spending also varies significantly between countries, with North America spending more than twice as much per capita as the European Union on average [6].
Hypertension has become the major cause of cardiovascular disease and early mortality globally [7].In 2019, it was found that around 1.28 billion adults aged 30-79 years worldwide had hypertension, with most (two-thirds) living in middle and low-income countries [8].Elevated blood pressure was responsible for an estimated 4.5 million deaths in men and 4.0 million in women in 2015 [9].The association between hypertension and premature deaths has also been recorded in several countries [10][11][12].
The increase in the incidence of hypertension is expected to continue [13].Therefore, hypertension should be detected early and managed properly through education and treatment [14].This can be managed through the use of telehealth [15].Telehealth can improve access for isolated people with hypertension in rural areas [16].Moreover, it might be an acceptable tool by using simple telehealth to diagnose and monitor hypertension among users [17].In addition, Blood Pressure Telemonitoring is useful both for screening and diagnosing hypertension as well as for improving hypertension management [18].Likewise, eHealth will support the creation of a network between healthcare professionals in improving screening, hypertension management, and related comorbidities and in the effective prevention of cardiovascular disease [19].
Telehealth technology in developing countries differs from that in developed countries in several ways.Firstly, in developing countries, there is a lack of resources in the health system, leading to challenges in implementing eHealth services [20].Additionally, the level of development in each country and the commitment of their governments to provide affordable healthcare services play significant roles in determining the success of eHealth models [21].Furthermore, the asymmetry among healthcare centers, hospitals, and userends poses a challenge in fully adopting telehealth technology in developing countries [22].On the other hand, in developed countries, telehealth services have been slow to be adopted, with uptake being piecemeal and ad hoc [23].
Telehealth can possibly work on the nature of medical services and patient fulfillment.Healthcare providers have widely adopted remote patient monitoring to reduce hospitalization rates and disease management to improve patient self-efficacy [24].Telehealth can potentially reform and transform the industry by reducing costs and improving quality, access, and patient satisfaction [25,26].Telehealth is well suited to support patients with chronic, complex, or comorbid conditions, [27] including hypertension.Several previous studies have reported the potential of telehealth to have a positive impact on hypertension management in primary healthcare [28][29][30][31].
The key barriers to hypertension control in primary care include a lack of effective screening and awareness, challenges with accessing treatment, difficulties in managing hypertension once it is treated, medication adherence barriers, lifestyle-related barriers, barriers related to the affordability and accessibility of care, and awareness-related barriers [32][33][34][35].Patient-related barriers, such as the misinterpretation of blood pressure readings, also contribute to the challenges in hypertension control [36].
Telehealth has shown benefits for hypertension management in primary healthcare.It has the potential to reduce barriers to accessing healthcare and improve clinical outcomes [37].Telehealth interventions have been used to treat patients with hypertension, heart failure, and stroke, with most interventions employing a team-based care approach [38].These interventions utilize the expertise of physicians, nurses, pharmacists, and other healthcare professionals to collaborate on patient decisions and provide direct care [39].Patients using telehealth have seen significant improvements in clinical outcomes such as blood pressure control, which are comparable to patients receiving in-person care [40].Telehealth can also support team-based care delivery and benefit patients and healthcare professionals by increasing opportunities for communication, engagement, and monitoring outside a clinical setting [41].
Previous literature review studies focused on the benefits and challenges of implementing telehealth in hypertension management in primary healthcare [42,43].However, research exploring the type of intervention and technology type of telehealth in hypertension management in primary healthcare has not been widely documented.This paper describes the characteristics of telehealth in hypertension management, which can later be used to improve the quality of hypertension services in primary healthcare.The purpose of this review was to identify information on types of interventions and technology from telehealth in the management of hypertension in primary healthcare (PHC) settings.

Method
The review follows the procedures and recommendations of the Joanna Briggs Institute (JBI) for conducting scoping reviews [44].The recent JBI guidelines categorize a scoping review as the optimal approach to comprehensively explore the existing literature on a subject by mapping and condensing accessible evidence.Additionally, scoping reviews are well suited to address areas lacking knowledge and offer valuable perspectives to aid decision-making.This evaluation also included PRISMA checklist instructions for reporting an accurate literature review [45].

Research Questions
In this study, we identified the characteristics of telehealth in hypertension management in primary healthcare through a scoping review by answering the research questions below: 1.
What kind of interventions are carried out in the management of hypertension in PHC settings?2.
What types of technology are used in the management of hypertension in PHC settings?

Research Strategy
The bibliographic databases, such as PubMed, Scopus, Science Direct, and Embase, with the aid of a medical research librarian, were used as a structured literature search in conducting the study.Research questions were developed using a PCC (hypertension, telehealth, and primary healthcare).The search strategy compromised search terms using Medical Subject Headings (MESH) for the concepts "telehealth", "hypertension", and "primary healthcare" in the health topic database.We used the Boolean operator AND OR.All references from the databases were exported to Mendeley for duplicating removal and final screening.For a total overview of the applied search, see Table 1.To find the selected article, the authors attempted to obtain full-text versions of the articles using Google Scholar, ResearchGate, and other databases.

Eligible Criteria
All reviewers used the inclusion and exclusion criteria to screen the titles, abstracts, and full articles.The articles we submitted referred to articles in the form of research results published in the last ten years (2013-2023) using the document language English.Articles in the form of scoping reviews, systematic reviews, and literature reviews, not in English and not available in full-text form, were excluded from this study.Publications meeting the inclusive criteria, and those for which the first reviewer (Y.P.) was in doubt, were reviewed a second time by other reviewers (S.N., N.S.).In terms of disagreement, a discussion between all reviewers determined inclusion or exclusion.

Study Selection
We searched and selected papers according to the criteria created and checked for duplicates of existing papers.Three people independently screened them according to title and abstract.The reasons for excluding existing papers until the final results of the selected studies were found are shown in Figure 1.Filters: in the last 10 years "Hypertension" [Mesh] OR "hypertensi" [tw] OR "high blood pressure" [tw] Filters: in the last 10 years "Primary Health Care" [Mesh] OR "primary health care" [tw] OR "primary care" [tw] Filters: in the last 10 years Scopus (TITLE-ABS-KEY (telemedicine) or title-abs-key ("mobile health") or title-abs-key (mhealth) or title-abs-key (ehealth) or title-abs-key (tele referral) and title-abs-key (hypertension) or title-abs-key ("high blood pressure") and title-abs-key ("primary health care") or title-abs-key ("primary care")) and pubyear > 2012 and pubyear > 2012 Science direct "high blood pressure" AND telemedicine OR "mobile health" OR "eHealth" AND "primary health care" Embase (('high blood pressure'/exp OR 'high blood pressure' OR 'hypertension'/exp OR hypertension) AND ('telemedicine'/exp OR telemedicine) OR 'mobile health'/exp OR 'mobile health' OR 'ehealth'/exp OR ehealth) AND ('primary health care'/exp OR 'primary health care') AND ((controlled clinical trial)/lim OR (randomized controlled trial)/lim) AND (2013-2023)/py

Data Extraction and Analysis
The data were extracted from chosen documents in full text in the following format: author, year, subject, intervention, type of population, type of technology, telehealth objectives, study design, country, software/hardware tools, and study outcomes.The extraction table is presented in Table 2.The results are presented in descriptive statistics, includ-

Data Extraction and Analysis
The data were extracted from chosen documents in full text in the following format: author, year, subject, intervention, type of population, type of technology, telehealth objectives, study design, country, software/hardware tools, and study outcomes.The extraction table is presented in Table 2.The results are presented in descriptive statistics, including frequency and percentage values, using Microsoft Excel 2019.The results of the scoping review of this study are presented in the form of map data on the distribution of telehealth use in various countries using the ArcGIS application.Data are presented in the form of diagrams and tables, according to the aim and scope of the review.Thematic analysis is presented based on the themes found.This procedure includes finding emerging patterns, assigning codes to the data, and combining these codes into broad themes that accurately express information to answer research questions [46].

Results
A sum of 1442 documents were identified after searching the selected databases.Also, 484 duplicates were removed.After sifting through 958 titles and abstracts, 440 articles were excluded.The remaining 518 articles were checked based on eligibility requirements, and we found 471 bibliography search results assessed for eligibility (including those papers that could not be obtained in full text).The remaining 47 articles were selected.Articles that were not set in primary healthcare and used the wrong document type were excluded in the final selection process, resulting in 42 articles being included in this study.The process of study selection is outlined in Figure 1.

Characteristics of Study
The articles included in this study were articles published between 2013 and 2023.Most of the research came from the United States (USA) (n = 10), followed by Brazil (n = 5) and the UK (n = 3), as shown in Figure 2a.According to the type of research, most of the studies included in this study used a quantitative approach followed by qualitative methods and mixed methods, as presented in Figure 2b.Regarding geographical settings, most studies were conducted in urban locations followed by rural locations, as presented in Figure 2c.The number of studies reporting the use of telehealth in hypertension management tended to fluctuate from 2013 to 2023.The highest numbers of published studies were reported in 2019 and 2022 (n = 7), as presented in Figure 2d.

Type of Intervention
We referred types of telehealth interventions based on the digital intervention categories promoted by WHO to ensure interoperability, i.e., teleconsultation, telemonitoring, teleassistance, and tele-expertise [88].We added one category telehealth intervention, i.e., tele-education, because some articles used tele-education as an intervention for hypertension management.In this study, we divided types of telehealth interventions into five categories, namely teleconsultation, telemonitoring, teleassistance, tele-expertise, and tele-education.The synthesis of selected paper data using thematic analysis shows that most hypertension management interventions in primary care are of the telemonitoring type, followed by teleconsultation and tele-education interventions, as presented in Table 3.
RQ 1.What are the interventions carried out in the management of hypertension in primary healthcare?

Key Themes References
Tele

Type of Intervention
We referred types of telehealth interventions based on the digital intervention categories promoted by WHO to ensure interoperability, i.e., teleconsultation, telemonitoring, teleassistance, and tele-expertise [88].We added one category telehealth intervention, i.e., tele-education, because some articles used tele-education as an intervention for hypertension management.In this study, we divided types of telehealth interventions into five categories, namely teleconsultation, telemonitoring, teleassistance, tele-expertise, and tele-education.The synthesis of selected paper data using thematic analysis shows that most hypertension management interventions in primary care are of the telemonitoring type, followed by teleconsultation and tele-education interventions, as presented in Table 3.
RQ 1.What are the interventions carried out in the management of hypertension in primary healthcare?We divided the types of telehealth intervention into three categories based on the study by Mechanic et al. [89], i.e., asynchronous, synchronous, and remote patient monitoring.The results of the data synthesis of selected papers using thematic analysis show that most interventions are of the telemonitoring type, followed by teleconsultation and teleeducation interventions, as presented in Table 4.

Discussion
This study aims to identify information related to the types of interventions and types of telehealth technology in managing hypertension in primary healthcare.There were 42 relevant studies in total that were included in the final synthesis.This study was a scoping review describing the utilization of telehealth in hypertension management in primary healthcare.The articles included in this study were published between 2013 and 2023.Most articles were from the US, followed by Brazil and the UK, most of which were implemented in urban areas.Based on research methods, most articles were analyzed using quantitative methods.
The results of our review show that telehealth management interventions in primary healthcare are dominated by telemonitoring (69%).Telemedicine in hypertension management should include the transmission of vital signs and remote monitoring [90].In the short-to-medium term, telemonitoring may be more effective than usual care [91].The implementation of telemonitoring for hypertension can be for routine primary healthcare on a large scale with little impact on physician workload [92].Telemonitoring can potentially improve the primary care management of Cardiovascular Disease (CVD) by improving patient outcomes and reducing healthcare costs [93].A literature review also reported that almost all studies reported that telemonitoring was able to reduce blood pressure in the subjects being measured [94].
Telehealth interventions for hypertension management often involve remote patient monitoring (RPM) devices, such as blood pressure monitors, to track patients' blood pressure levels [95].These interventions typically employ a team-based care approach, involving physicians, nurses, pharmacists, and other healthcare professionals collaborating on patient decisions and providing direct care [38].Patients using telehealth for hypertension management have seen significant improvements in clinical outcomes, including blood pressure control, which are comparable to patients receiving in-person care [40].
Apart from telemonitoring, our findings also found teleconsultation to be a frequently used intervention in hypertension management in primary care.Teleconsultation is an effective alternative to face-to-face consultation for many patients presenting to primary healthcare [96].Teleconsultations between non-physicians and doctors located remotely have the potential to reduce the number of referrals to central clinics [97,98].Teleconsulting services improve the compatibility of primary services and integration with secondary services in rural communities [99].
Our findings show that hypertension management technology in primary healthcare predominantly uses asynchronous technology.Most recent generation telemedicine systems use an asynchronous telemedicine approach [100].This technology is reliable, simple to operate, has consistent connections, uses standard communication protocols, and has efficient bandwidth.For example, eHealth and mHealth are gradually gaining key roles in managing hypertensive patients [19].Additionally, Java client applications that send digital camera images and structured XML text as e-mails are designed for use in resource-poor, poorly networked developing countries [101].The application of advanced technology in rural healthcare settings has the potential to lower the cost of patient care and managed care insurance plans, enabling expert consultation from remote centers [102].Asynchronous telehealth can shorten waiting times, reduce unnecessary referrals, and increase patient and provider satisfaction levels [103].
Our findings show that telehealth is currently being utilized to help manage hypertension in primary healthcare.It also helps to provide remote access to healthcare professionals and enables the monitoring of blood pressure [37,95].It has been increasingly used during the COVID-19 pandemic to ensure continuity of care and improve access to healthcare services [104].Studies have shown that telehealth interventions, including remote patient monitoring (RPM) and team-based care, have been effective in treating patients with hypertension and cardiovascular disease (CVD) [37].A collaborative nephrologist-pharmacist telehealth clinic has also been successful in improving difficult-to-control hypertension in patients with chronic kidney disease (CKD) [105].Telehealth-delivered approaches, such as the TEAM intervention, have been shown to improve hypertension care delivery and blood pressure control [39].The COVID-19 pandemic has further accelerated the use of telehealth for the management of hypertension and other non-communicable diseases (NCDs) [39].
Overall, telehealth has the potential to reduce barriers to accessing healthcare, improve clinical outcomes, and extend services to remote areas, making it a valuable tool in the management of hypertension in primary healthcare settings.
Health systems and healthcare differ between countries.Despite these differences, most health systems aim to improve patient health, be responsive to patient needs, and ensure financial sustainability [106].Developing countries face more challenges in building strong and reliable health systems compared to developed countries, leading to disparities in public health status and health problems [3].Health inequalities exist within and between countries, with socioeconomic and cultural inequalities driving health inequities [106].
Our findings show that different countries use different technologies for hypertension management.Telehealth and eHealth technology availability differ between developed and developing countries.In developed countries, the use of telehealth and eHealth services has been increasing, especially during the COVID-19 pandemic [107].These countries have reached thresholds for telehealth provision, such as a certain level of telecommunication accessibility, a proportion of elders exceeding 10%, or a proportion of health spending occupying more than 3-5% of GDP [108].On the other hand, developing countries are also utilizing telehealth and eHealth technology, but the models and approaches vary depending on the level of development and government commitment to providing affordable healthcare services [109].

Strengths and Limitations
This study captured the use of telehealth for hypertension management in primary healthcare.The selection process uses four databases with systematic procedures.With wide location coverage, it can describe the implementation of telehealth in various countries.One limitation of this study was that it did not include grey literature reviews in the inclusion criteria.Another limitation was language bias because we searched for articles in English only.Future studies can overcome this limitation.

Conclusions
Telehealth is considered to have the potential for the management of hypertension in primary care.The findings of this study show that telehealth interventions in hypertension management in primary healthcare are dominated by telemonitoring.The technology used is more common in asynchronous telehealth.Further studies are needed to evaluate telehealth services in supporting the management of hypertension in primary care.

Figure 1 .
Figure 1.Flowchart of the PRISMA scoping review study identification and selection process.

Figure 1 .
Figure 1.Flowchart of the PRISMA scoping review study identification and selection process.

Figure 2 .
Figure 2. characteristics of telehealth in hypertension management in primary care settings.

Figure 2 .
Figure 2. Characteristics of telehealth in hypertension management in primary care settings.

Table 1 .
Search strategy for databases.

Table 2 .
Data extraction results.

Table 3 .
Thematic synthesis based on type of intervention.